Clinical Pearls on Best Approaches to Psychogenic Movement Disorders: Page 4 of 4

REFERRAL: PSYCHIATRIST OR PSYCHOLOGIST?
Treatment may involve sessions with a psychiatrist, a psychologist, or both. Hinson prefers to refer patients to a psychiatrist who has a special interest in somatoform disorders, but said any reputable psychiatrist would be suitable. If patients are recruiting their own mental health professional, Hinson requests that the patient have the psychiatrist call her. "The psychiatrist often needs reassurance from the neurologist that the condition is indeed psychogenic," she said.

The psychiatrist will devise a treatment plan that might include psychotherapy (either psychodynamic therapy or cognitive behavioral therapy); stress management and relaxation techniques such as biofeedback, yoga, and meditation; and medication for associated depression and anxiety. Many psychiatrists will refer the patient to a psychologist for the psychotherapy or stress management components. In addition, some patients may benefit from treatment by a physical or occupational therapist to reestablish normal motor function.

About half of Hinson's patients in whom a PMD diagnosis is made are requested to check back with Hinson after 3 months of once-weekly psychotherapy. "Some patients do well with the reassurance that someone is overseeing the treatment process," she said.

Jankovic's preference is to send patients directly to psychologists, especially those who specialize in stress management techniques such as biofeedback. He and his colleagues at Baylor have recently embarked on an independent review board-approved study of transcutaneous nerve stimulation as a means of "relaxing" the abnormally contracting muscles.

PROGNOSIS
Few studies have looked at the long-term outcome of PMD. However, there is evidence that persons who are least likely to recover are those who are symptomatic for more than 6 months; those with insidious onset of PMD; and those with a primary psychiatric diagnosis of hypochondriasis, factitious disorder, or malingering.

In the largest longitudinal study to date (228 patients seen at the Baylor Movement Disorders Clinic), nearly 57% of patients improved, 22% worsened, and 21% remained the same after an average follow-up of 3.4 years. Patients who were most likely to recover were those in good physical health, with positive perceptions of their social life, who perceived that they were receiving effective treatment, who eliminated stressors in their life, and who were treated with a specific medication.10

"We found that patients who initially accept their diagnosis do well," said Jankovic. Hinson agreed. "I think we can prevent a lot of harm by delivering the diagnosis quickly and precisely and not shying away from it," she said. "We can see very good success with the appropriate treatment."